Correct!
5. Perform MRI choleopancreatography
Among the choices listed, MR choleopancreatography (MRCP) is the most reasonable answer. Surgical removal of the gallbladder, either by laparoscopic or open cholecystectomy, is premature at this point. Although the patient does have right upper quadrant pain, there are numerous causes of such pain and thus far there are few data implicating the biliary system as the cause of her pain- her liver and biliary enzymes were normal and her right upper quadrant ultrasound examination was unremarkable. The “sluggish” appearance of tracer in the gallbladder at nuclear medicine scintigraphy (HIDA scan) is very non-specific. The absence of tracer accumulation within the gallbladder is taken as evidence of acute cholecystitis, but this was not the test result. Rather, the “delayed” appearance of tracer in the gallbladder can be associated with chronic cholecystitis, as can “reduced gallbladder ejection fraction,” but these findings are non-specific. Commonly, chronic cholecystitis is associated with gallstones, which were not seen in this patient, so the equivocal findings at nuclear medicine scintigraphy should be regarded with suspicion. For this reason, before any invasive intervention is planned, further data supporting a biliary cause for the patient’s presentation is needed, and MR choleopancreatography could be helpful in this regard. 18FDG-PET scan does not play a role in the evaluation of patients with acute presentations in the Emergency Room.
The patient underwent laparoscopic cholecystectomy. Her patient persisted post-operatively and she re-presented to her physician in an outpatient setting with the same complaints of right chest and upper quadrant pain. See underwent frontal chest radiography (Figure 1).
Figure 1. Initial frontal chest radiography.
Which of the following represents an appropriate interpretation of her frontal chest radiograph? (Click on the correct answer to be directed to the fourth of thirteen page